Ultrasound and subtle lab findings may convince you to admit that patient with RUQ pain.

It’s another hectic day in paradise when your resident asks if she can present a case to you. The patient is a 49-year-old female who presents to the ED for abdominal pain. The patient states that three days ago she had an episode of epigastric pain that came on suddenly, was bad for about an hour, and then gradually resolved over about three hours. Today it recurred, but is more severe, 9 out of 10, and radiates to the right upper quadrant. It has been present for over 10 hours and is getting no better. She states that she vomited once and has chills but doesn’t think she has had a fever. She took ibuprofen about an hour ago for the pain, noting that it hasn’t really helped. She denies any other complaints.



在分類中的PA在一個半個小時半前訂購了實驗室,它們已經導致並顯示了以下內容:WBC 5.7,血紅蛋白12.3,化學和LFTS全麵限製。您的居民為您帶來了以下圖像,她用自己的床位超聲圖保存。她告訴你她的計劃,“這看起來像沒有真正的紅旗的簡單膽結石。我們可以用氫化氫化酮送她的家,並安排正式的超聲波和外科谘詢作為門診?“

Q: Do you sign off on your resident’s management plan? What do the images show?


Do not sign off on this plan! Before we get to the images, there are indeed multiple red flags here. First, the duration of the pain: pain of a presumed biliary origin that lasts more than six hours is cholecystitis until proven otherwise, so formal imaging is indicated here (see the EM 1-minute consult on cholecystitis below for more clinical pearls and pitfalls). The second red flag is the vital signs: a pulse of 97 is under 100, but is a little on the high side and a blood pressure of 93/61 is probably not normal in a 49-year-old obese female with 9/10 pain, neither are respirations of 22, and a temperature of 98.9 an hour or two after ibuprofen could represent a fever, especially in a patient with chills.

The third red flag is the physical exam: a positive Murphy’s sign is an exam finding that has been described in cholecystitis, not biliary colic.




The images show two transabdominal views of the gallbladder. The first shows a large gallstone with posterior shadowing that is possibly impacted in the gallbladder neck. To the right side of the image, near the gallbladder fundus, there is also shadowing but no evidence of stones. This could be due to an air collection from gallbladder rupture (see labeled ultrasound below). The second image above focuses on this area and shows a non-descript area with shadowing that is probably free air, consistent with a perforated gallbladder from cholecystitis.

A confirmatory CT scan (shown below) was requested by the surgical consult. Note the pericholecystic fluid but also the fluid collection medial to the posterior liver and lateral to the right kidney, as well as free air anterior and medial to the gallbladder.

The patient received IV ampicillin/sulbactam and was taken emergently to the operating room. Fortunately, she did well and followed up in the post-operative surgical clinic rather than in the septic-shock or ascending cholangitis clinic.

Pearls and Pitfalls:Gallbladder & RUQ Ultrasound

  1. 了解您的限製:超聲波可以幫助澄清結果引起的thorough history and physical exam. When used correctly, it can greatly improve diagnostic accuracy and help guide patient management, especially for time-critical diagnoses and treatment of unstable patients. It can also decrease the use of CT scan and thereby minimize radiation exposure. However, you need to consider your skill level and know your limitations. When unsure, order a formal study. If your department has an ED dedicated ultrasound machine, it should consider implementing a quality improvement program that is approved by both ED administration and radiology.
  2. Finding the Gallbladder:在左側躺在患者並通過定位下肝邊緣可以幫助。
  3. 超聲墨菲的標誌:要檢查超聲靜脈炎的超聲波墨跡的標誌,請將超聲探頭放在右上象限的最大溫柔點。如果探頭在膽囊眼底上放置直接壓力,你有一個積極的超聲墨菲的標誌。如果患者在考試前接受鴉片劑,可能會偶爾發生錯誤的否定。
  4. 膽囊牆:One sign of cholecystitis is a thickened gall-bladder wall. The normal gallbladder wall can be up to 3mm thick. The most common conditions other than cholecystitis that may cause thickening of the gallbladder wall include hepatitis, hypoalbuminemia, tumor, hyperplastic cholecystosis, adenomyomatosis, and CHF. In the absence of ascites, the presence of pericholecystic fluid, also supports the diagnosis of acute cholecystitis. If there is clinical uncertainty, a nuclear biliary scan (HIDA or DESIDA scan) may be performed.
  5. 常見的膽管:A dilated common bile duct is another sign of acute cholecystitis. The normal common bile duct inner diameter should be less than 4mm, but may be higher, up to 10mm, post-cholecystectomy. In addition, the diameter may be higher in older patients, up to 1mm per decade of life.
  6. 膽囊內容:尋找一個擴張膽囊,石頭的證據, and for sludge. Gallstones should be mobile, unless they are impacted in the gallbladder neck, and should cast an acoustic shadow. If all stones are mobile in a patient who remains symptomatic, consider that they may be a red herring and not the true cause of the patient’s pain. Remember that approximately 15% of adults have asymptomatic gallstones. If there are no sonographic signs of cholecystitis, but a gallstone is impacted (non-mobile) in the gallbladder neck, be suspicious for early cholecystitis and consider admission, additional imaging, or at least next-day follow-up. Always also consider early cholecystitis when pain lasts for more than six hours, even when the ultrasound is normal except for the presence of a stone. Uncomplicated gallstone attacks usually should only last a few hours. Make sure to explain this to patients if you for some reason decide to send them home with opiates. Attacks lasting longer than that may be something more serious.
  7. Pitfalls:不要錯過隱藏在膽囊頸部的一個障礙膽結石。它有時會很難看到。此外,不要被偶然的“紅鯡魚”膽結石偽造出來。如前所述,許多人有多年的膽結石,無症狀,所以如果一切都不臨床,那麼看看別人導致腹部,側翼或肋骨疼痛。一些實例包括主動脈瘤,Fitz-hugh-curtis綜合征,高闌尾炎,Pe,腎結石和肺炎。最後,不要錯過一個AAA,即使它也是偶然的,因為你沒有尋找它。超聲波技術看。主動脈並不是那麼遙遠,應該在50歲以上的任何人常規檢查腹部超聲的任何人。篩選拯救生命!


EMERGENCY ULTRASOUND SECTION EDITOR Dr. Pregerson manages a free online EM Ultrasound Image Library. He is the author of the Emergency Medicine 1-Minute Consult Pocketbook and the A to Z Pocket Emergency Pharmacopoeia & Antibiotic Guide (available atEmresource.org.) and the Tarascon Emergency Department Quick Reference Guide (Tarascon.com).


  1. I have had upper right quadrant pain on and off for years.
    the past year its been bad, but not always when I eat, it can start just with excise, or movements.
    I also had a gallbladder empty study which they said was ok……Any suggestions? I am desperate

  2. Trevor Wuotion

    I had pain basically below the breast bone varying levels of pain and not related to eating. Varying levels of pain extending to the right and earlier in the piece to the left just below the ribs and finally in my back on the right side where the right lung would be. I had this pain for 12 months and was treated for IBS which my symptoms did not support.


    No more chronic and repeated pain.. Seems that the US an CT can’t see the issue but after I receive pathology results this week I am going to request a re-read of the CT so that the doctors learn and can hopefully pinpoint the issue for other patients.

  3. Amber Henleyon

    I have ha gallbladder stones for over three months now. I only found out two months ago, because I had been having chronic diarrhea everyday for a month. And had 5-8 episodes that day. My abdomen was super tight, and my liver enzymes were elivated.

    我終於找到一個,一直到the ER again since then, because of servere pain in my upper right flank that made me cry, but they just keep saying it’s just stones, and I should look into having the organ removed.

    I’ve been having servere pain, chills and diarrhea daily. I feel a stabbing pain under my ribs that runs down my right flank burning, and even got so disoriented, I almost fell and fainted several times at the doctor’s.. I’m scared, and my appointment isn’t for 11 days to even get examined for surgery. I also have a MRSA skin infection that my doctor’s refuse to treat for over a year. I don’t know what to do.
    Any tips? Could my gallbladder already be leaking?

    • Am I reading this right? Your doctor won’t treat your MRSA? You need a new doctor. They work for you, not the other way round!

    • Hi AMBER, you MUST read “The Liver and Gallbladder Miracle Cleanse” by ANDREAS MORITZ / the title literally speaks for itself, and the REVELATION will amaze you I’m sure, like it has for me. Started reading the book end-2019; and started my journey January 2020 – I do very much recommend reading the book for yourself, and not rely on 2nd hand download. There are many “testimonies ” on the internet; sure I’ve listened, but one will find the exact information in this book. I can chat about this all day long…

  4. What effect on digestion system would you expect from gallbladder during attack, if any?
    My right side in tender to touch right below rib.

  5. I have had chronic diarrhea for around 7 months now. Some days I got 2-3 times and other 10 times . I got into my gi dr but it was when this whole COVID thing started and non emergent procedures were cancelled. One day I started having pains in my chest that keep coming back. I went to the Ed when it went on for about 2 hours because I have a history of coronary artery disease and it scared me. They ran all kinds of tests and had a stress test that all were fine. Pains have continued. My gi did an endoscopy scope down into my stomach with no findings. I had a gall bladder ultrasound with no findings except a possible kidney issue. Gi decided to try me on nitroglycerin to see if it is esophageal spasms but that is not working either. I feel tired all the time and still have pain. Family history of gallbladder disease. I don’t know what I should do. I’m in pain while writing this.

  6. Sylviane Blosson

    I’m veryyy discouraged at the medical care in emergency rooms I’m 69 and finally went to ER for after five days constant on and off upper right side,, had no fever, blood pressure 135/83,, no chills just horrible pain and nausea,, doctor never examined me, just ordered labs and ultrasound, comes back in room an hour later says allll is well,what the heck!! I asked him to please do catscan because I have brain tumor and was told several years ago I have a growth also on my liver, I explain to the doctor that my stools had turned yellow within a week that is not normal so I thought it was my gallbladder he insisted that it was not the gallbladder never said anything else they did the CAT scan and within 15 minutes they came in my room and told me I was fine,, they had the clipboard ready to zoom me out of the hospital room like I said I’m 69-year-old female with brain tumor and I have another tumor in my left long as well they treated me and shoved me out!! My son drove me home and I am still at home suffering not knowing what to do

  7. 善良的上帝謝天謝地,我不住在你們所有人都是我們的nhs絕對夢幻般的我的心來向你們所有人都祈禱我祈禱你們所有人都會很快放心你的痛苦xx

  8. I’m a 29 year old female. Was diagnosed with gallstones a year ago because I had really bad pain in upper right side of abdomen so I went to urgent care and they sent me to do sonograms. So I did and they found 2 gallstones. For a few months after that I didn’t have any pain related to gallbladder so I thought surgery may not be necessary since I didn’t feel pain anymore. Now fast forward to a month ago. I been having on and off pain almost everyday. Feels like trapped gas. Sometimes it’s sharp sometimes it just a discomfort. some days it’s for a while but days like today I been having the pain all day on and off. It’s a pain I feel higher above my right breast and sometimes near my right armpit. I’m scared and don’t know if I should go to ER or just to see if it pain goes away. I don’t have fever or chills or vomiting. My stools have started to change color but I’m also on medication for H. Pylori so I don’t know if it could be that. I’m sick and tired of feeling this pain everyday and im afraid that my gallbladder will burst. What do you think I should do ?

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